Youth At Risk 
Screening Questionnaire

The following is a list of behaviors that are associated with Youth at Risk. Circle the items that describe the youth you are concerned about.  Add the numbers up. A list of ranges are provided below.  You may also check the boxes next to each question and submit the form to us by e-mail for feedback. These ranges indicate a level of risk that your child's problem behavior will escalate without intervention.  

Professional consultation is always appropriate if you have concerns regarding mental, emotional or behavioral problems.  This questionnaire should not be used to screen for medical, psychiatric or mental health disorders.  No questionnaire can replace or substitute for professional consultation.  This questionnaire is designed to help you clarify your concerns, help you discuss issues with a counselor or mental health professional and to give you an indicator of approximate risk.


Date Form Completed:  
Month     Day of Month:    Year: 2004

Child's First Name:      Last Name:

Date Of Birth:      
Month:     Day Of Month:    Year:

Age:     Gender:  

Person Completing The Form: 
First Name:     Last Name:

Your Relationship To The Child: 

E-mail Address (required):

State Where You Live (required):

Please be sure your e-mail address is correct if you want a response.

 

Check Value Question
1 1. Does not follow through with instruction and fails to complete tasks
1 2. Has difficulty organizing tasks or activities
1 3. Avoids, dislikes and is reluctant to engage in tasks that require effort
1

4. Has difficulty waiting or taking turns

1

5. Interrupts or intrudes on others

1 6. Is overly concerned with the opinions of friends
1

7. Is being used by other kids who are not good friends

1

8. Stealing without confronting a victim

1

9. Truancy from school

1

10. Easily frustrated or impatient with simple and reasonable rules

1

11. Swears

1

12. Pushes people away but then desperately wants them back

1

13. Touchy or easily annoyed by others

1

14. Easily frustrated and upset by events or circumstances

1

15. Blames others for circumstances without good reason

1

16. Blames others for his or her own mistakes

1

17. Avoids healthy family or social activities

1

18. Argues with adults over little things

5

19. Lying

5

20. Actively defies or refuses the requests of adults

5

21. Deliberately does things to annoy people

5

22. Quick to react with anger

5

23. Spiteful or vindictive

5

24. Often late without good reason

5

25. Frequent (at least daily) emotional outbursts and mood swings

5

26. Reckless or irresponsible behavior

5

27. Their efforts to solve their problems are not reasonable and are not effective

5

28. Doesnt seem to learn from mistakes and then change their behavior

5

29. Seems unable to see things from another persons point of view

5

30. Reacts to criticism or consequences with feelings of intense guilt, anger or depression

5

31. Responds with rage, profanity or yelling when their point of view is not accepted

5

32. Requires an excessive amount of attention and support

5

33. Avoids discussing or ignores the impact of their behavior on others

5

34. Tries to negotiate, get out of problems and avoid consequences

5 35. Is manipulative and deceptive
5

36. Does not follow through with promises

5

37. Running away from home

10

38. Deliberate destruction of property or the belongings of others

10

39. Mental or emotional cruelty to others

10

40. Justifies hurting others who resist being manipulated or controlled

10

41. Initiating physical fights

10 42. Has been in counseling or therapy and has not benefited
15

43. Breaking into someone's house, building or car

15

44. Stealing when confronting a victim

15

45. Friends and family suspect a drug problem

15

46. Refuses to acknowledge even the obvious consequences or symptoms of drug use

15 47. Has or is currently on medication for mental, emotional or behavioral problems
20 48. Threatens parents with violence, self-harming or self-destructive behavior
20

49. Denies solid evidence of their drug use

20

50. Cruelty to animals

20 51. Physical cruelty to others

 

_______  TOTAL 

There are three steps in processing this questionnaire.

1.  Print this form with your answers and total the points.

RISK SCORE
Low 5 to 16
Moderate 17 to 32
High 33 to 84
Extremely High 85 or more

2.  Ask a question below.

 Contact a qualified mental health professionals if there is a crisis. 
Contact police or 911 if there is a danger to yourself, others, children or elderly people. 
We generally respond to questions in 1 to 3 days. 

3. Submit this form my e-mail. Your response will be kept private.
Use of e-mail is more secure than ground mail or FAX.

 

After your submit this form, a results page will appear along with a brief list of resources and helpful interpretation material.

         

 

Copyright 1999 to 2004, Mentor Research Institute